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Objectives: To investigate intra- and inter-reader agreement of ultrasonography (US) and conventional radiography (CR) for the evaluation of osteophyte presence and size within the tibiofemoral joint. In addition, to correlate these findings with arthroscopic degeneration of the articular cartilage.Method: Forty adult patients with knee pain were enrolled in this study. Knee CR and US scanning of the medial and lateral bone margins were performed on all patients. A novel atlas for the US grading of knee osteophytes was used in the evaluation. The number and size of the osteophytes were evaluated semi-quantitatively in two rounds from both the CR images (four readers) and the US images (14 readers). The Noyes grading system was used for the evaluation of arthroscopic degeneration of the articular cartilage in 26 patients.Results: On average, intra- and inter-reader US and CR agreement was substantial and comparable to each other (κ = 0.60-0.72). US detected more osteophytes than CR at both the medial (65% vs. 48%) and lateral (70% vs. 60%) compartments. A statistically significant correlation between CR- or US-based osteophyte and arthroscopy grades was observed only for US at the medial compartment (rs = 0.747, p < 0.001).Conclusions: The detection of knee osteophytes using the novel US atlas is as reproducible as reading conventional radiographs. US is more sensitive to detect knee osteophytes than CR. Furthermore, osteophytes detected with US correlate significantly with arthroscopic cartilage changes at the medial knee compartment whereas those detected by CR do not. [ABSTRACT FROM AUTHOR]

Objective: The main aim was to investigate the associations between Magnetic Resonance Imaging (MRI)-defined structural pathologies of the knee and physical function., Design: A cohort study with frequency matching on age and sex with eighty symptomatic subjects with knee pain and suspicion or diagnosis of knee osteoarthritis (OA) and 57 asymptomatic subjects was conducted. The subjects underwent knee MRI, and the severity of structural changes was graded by MRI Osteoarthritis Knee Score (MOAKS) in separate knee locations. WOMAC function subscores were recorded and physical function tests (20-m and 5-min walk, stair ascending and descending, timed up & go and repeated sit-to-stand tests) performed. The association between MRI-defined structural pathologies and physical function tests and WOMAC function subscores were evaluated by linear regression analysis with adjustment for demographic factors, other MRI-features and pain with using effect size (ES) as a measure of the magnitude of an association., Results: Cartilage degeneration showed significant association with poor physical performance in TUG-, stair ascending and descending-, 20-m- and 5-min walk-tests (ESs in the subjects with cartilage degeneration anywhere between 0.134 [95%CI 0.037-0.238] and 0.224 [0.013-0.335]) and with increased WOMAC function subscore (ES in the subjects with cartilage degeneration anywhere 0.088 [0.012-0.103]). Also, lateral meniscus maceration and extrusion were associated with poor performance in stair ascending test (ESs 0.067 [0.008-0.163] and 0.077 [0.012-0.177])., Conclusions: After adjustments cartilage degeneration was associated with both decreased self-reported physical function and poor performance in the physical function tests. Furthermore, subjects with lateral meniscus maceration and extrusions showed significantly worse performance in stair ascending tests., (Copyright © 2017 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Purpose: To evaluate adiabatic T 1ρ and T 2ρ of articular cartilage in symptomatic osteoarthritis (OA) patients and asymptomatic volunteers, and to determine their association with magnetic resonance imaging (MRI)-based structural abnormalities in cartilage and bone., Materials and Methods: A total of 24 subjects (age range: 50-68 years; 12 female) were enrolled, including 12 early OA patients and 12 volunteers with normal joint function. Patients and volunteers underwent 3T MRI. T 2 , adiabatic T 1ρ , and T 2ρ relaxation times of knee articular cartilage were measured. Proton density (PD)- and T 1 -weighted MR image series were also obtained and separately evaluated for morphological changes using the MRI OA Knee Scoring (MOAKS) system. Comparisons using the Mann-Whitney nonparametric test were performed after dividing the study participants according to physical symptoms as determined by Western Ontario and McMaster Universities (WOMAC) score or presence of cartilage lesions, bone marrow lesions, or osteophytes., Results: Elevated adiabatic T 1ρ and T 2ρ relaxation times of articular cartilage were associated with cartilage loss (P = 0.024-0.047), physical symptoms (0.0068-0.035), and osteophytes (0.0039-0.027). Elevated adiabatic T 1ρ was also associated with bone marrow lesions (0.033)., Conclusion: Preliminary data suggest that elevated adiabatic T 1ρ and T 2ρ of cartilage are associated with morphological abnormalities of cartilage and bone, and thus may be applicable for in vivo OA research and diagnostics., Level of Evidence: 2 Technical Efficacy: Stage 2 J. MAGN. RESON. IMAGING 2017;46:678-689., (© 2017 International Society for Magnetic Resonance in Medicine.)

The aetiology of knee pain in osteoarthritis (OA) is heterogeneous and its relationship with structural changes and function is unclear. Our goal was to determine the prevalence of wide-area scanned ultrasound-defined knee OA structural features and their association with pain and functional impairment in 79 symptomatic and 63 asymptomatic subjects. All subjects underwent ultrasound knee wide-area scanning and the severity of articular cartilage degeneration, the presence and size of osteophytes, and meniscal extrusion were evaluated. Subjects filled in a self-administrated questionnaire on present knee pain, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) on clinical symptoms and function over the past week. Cartilage changes were the most prevalent followed by lateral meniscal extrusion, osteophytes and medial meniscal extrusion. The global femoral cartilage grade associated strongly with pain and the WOMAC index. Site-specifically, early medial cartilage changes and thinning in sulcus and lateral site were associated with symptoms. The presence of femoral lateral osteophytes was also associated with both outcomes. Using the novel wide-area ultrasound scanning technique, we were able to confirm the negative impact of femoral cartilage OA changes on clinical symptoms. Presence, not necessarily size, of lateral femoral osteophytes was also associated with increased pain and disability.

Objective: To determine the associations between multi-feature structural pathology assessed using magnetic resonance imaging (MRI) and the presence of knee pain, and to determine the associations between the locations of structural changes and different knee pain patterns., Method: Eighty symptomatic subjects with knee pain and suspicion or diagnosis of knee OA and 63 asymptomatic subjects underwent knee MRI. Severity of structural changes was graded by MRI Osteoarthritis Knee Score (MOAKS) in separate knee locations. The associations between cartilage damage, bone marrow lesions (BMLs), osteophytes, Hoffa's synovitis, effusion-synovitis, meniscal damage and structural pathologies in ligaments, tendons and bursas and both the presence of pain and the knee pain patterns were assessed., Results: The presence of Hoffa's synovitis (adjusted RR 1.6, 95% CI 1.2-1.3) and osteophytes in any region (2.07, 1.19-3.60) was significantly associated with the presence of pain. Any Hoffa's synovitis was associated with patellar pain (adjusted RR 4.70, 95% CI 1.19-3.60) and moderate-to-severe Hoffa's synovitis with diffuse pain (2.25, 1.13-4.50). Medial knee pain was associated with cartilage loss in the medial tibia (adjusted RR 2.66, 95% CI 1.22-5.80), osteophytes in the medial tibia (2.66, 1.17-6.07) and medial femur (2.55, 1.07-6.09), medial meniscal maceration (2.20, 1.01-4.79) and anterior meniscal extrusions (2.78, 1.14-6.75)., Conclusions: Hoffa's synovitis and osteophytes were strongly associated with the presence of knee pain. Medial pain was associated most often with medially located structural pathologies., (Copyright © 2016 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Osteoarthritis (OA) is a common degenerative musculoskeletal disease highly prevalent in aging societies worldwide. Traditionally, knee OA is diagnosed using conventional radiography. However, structural changes of articular cartilage or menisci cannot be directly evaluated using this method. On the other hand, ultrasound is a promising tool able to provide direct information on soft tissue degeneration. The aim of our study was to systematically determine the site-specific diagnostic performance of semi-quantitative ultrasound grading of knee femoral articular cartilage, osteophytes and meniscal extrusion, and of radiographic assessment of joint space narrowing and osteophytes, using MRI as a reference standard. Eighty asymptomatic and 79 symptomatic subjects with mean age of 57.7 years were included in the study. Ultrasound performed best in the assessment of femoral medial and lateral osteophytes, and medial meniscal extrusion. In comparison to radiography, ultrasound performed better or at least equally well in identification of tibio-femoral osteophytes, medial meniscal extrusion and medial femoral cartilage morphological degeneration. Ultrasound provides relevant additional diagnostic information on tissue-specific morphological changes not depicted by conventional radiography. Consequently, the use of ultrasound as a complementary imaging tool along with radiography may enable more accurate and cost-effective diagnostics of knee osteoarthritis at the primary healthcare level.

[This corrects the article DOI: 10.1155/2013/182562.].

Objective: To produce educational guidelines for the conduct, content and format of theoretical and practical teaching at EULAR musculoskeletal ultrasound (MSUS) Teaching the Teachers (TTT) Courses., Methods: A Delphi-based procedure with 24 recommendations covering five main areas (Duration and place of the course; Faculty members; Content of the course; Evaluation of the teaching skills; TTT competency assessment) was distributed among a group of experts involved in MSUS teaching, in addition to an advisory educational expert being present. Consensus for each recommendation was considered achieved when the percentage of agreement was >75%., Results: 21 of 24 invited participants responded to the first Delphi questionnaire (88% response rate). All 21 participants also responded to the second round. Agreement on 19 statements was obtained after two rounds., Conclusions: This project has led to the development of guidelines for the conduct, content and format of teaching at the EULAR MSUS TTT Courses that are organised annually, with the aim of training future teachers of EULAR MSUS Courses, EULAR Endorsed MSUS Courses, as well as national and local MSUS Courses. The presented work gives indications on how to homogenise the teaching at the MSUS TTT Courses, thus resolving current discrepancies in the field.

A potential of quantitative noninvasive knee ultrasonography (US) for detecting changes in femoral subchondral bone related to knee osteoarthritis (OA) was investigated. Thirty-nine patients referred to a knee arthroscopy underwent dynamic noninvasive US examination of the knee joint. The subchondral bone was semiautomatically segmented from representative US images of femoral medial and lateral condyles and intercondylar notch area. Subsequently, the normalized mean gray-level intensity profile, starting from the cartilage-bone interface and extending to the subchondral bone depth of -1.7 mm, was calculated. The obtained profile was divided into 5 depth levels and the mean of each level, as well as the slope of the profile within the first two levels, was calculated. The US quantitative data were compared with the arthroscopic Noyes' grading and radiographic Kellgren-Lawrence (K-L) grading. Qualitatively, an increase in relative subchondral bone US gray-level values was observed as OA progressed. Statistically significant correlations were observed between normalized US mean intensity or intensity slope especially in subchondral bone depth level 2 and K-L grading (r = 0.600, P < 0.001; r = 0.486, P = 0.006, resp.) or femoral arthroscopic scoring (r = 0.332, P = 0.039; r = 0.335, P = 0.037, resp.). This novel quantitative noninvasive US analysis technique is promising for detection of femoral subchondral bone changes in knee OA.

US allows us to detect joint alterations and to perform procedures such as aspiration of fluid as well as therapeutic injections; it helps in placing the needle correctly, greatly improving the outcome. Tissue biopsies (of, for example, synovium, muscle or salivary glands) can be performed with US guidance, and this method may be of significant importance in diagnostic examinations. Other imaging methods may be fused with US, and thus detailed maps are available to navigate in soft tissues. The new era in rheumatology will include US as an important part of its armament.

Objective: To investigate the diagnostic performance of non-invasive knee ultrasonography (US) to detect degenerative changes of articular cartilage using arthroscopic grading as the gold standard., Design: Forty adult patients referred to a knee arthroscopy because of knee pain were randomly selected for the study. Before the arthroscopy, knee US was performed and cartilage surfaces at medial and lateral femoral condyles as well as at intercondylar notch area (sulcus) were semi-quantitatively graded from US. Ultrasonographic grading was compared with the arthroscopic Noyes' grading for cartilage degeneration., Results: Sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic odds ratio for detecting arthroscopic cartilage changes in US varied between 52 and 83%, 50-100%, 88-100%, 24-46%, and 5.0-13.0, respectively, depending on the site. Correlation of severity of cartilage changes (grades) between US and arthroscopy varied from insignificant to significant depending on the site: at the sulcus area the correlation was highest (r(s)=0.593, P<0.001), at the medial condyle also significant (r(s)=0.465, P=0.003), and at the lateral condyle non-significant (r(s)=0.262, P=0.103). The sum of cartilage grades in all three sites of the femoral cartilage between US and arthroscopy had the highest correlation (r(s)=0.655, P<0.001)., Conclusions: Positive finding in US is a strong indicator of arthroscopic degenerative changes of cartilage, but negative finding does not rule out degenerative changes. Non-invasive knee US is a promising technique for screening of degenerative changes of articular cartilage, e.g., during osteoarthritis., (Copyright © 2012 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Objectives: To document the practice and training opportunities of US-guided arthrocentesis and joint injection (UGAJ) among rheumatologists in the member countries of the European League Against Rheumatism (EULAR)., Methods: An English-language questionnaire, containing questions on demographics, clinical and practical aspects of UGAJ, training options in UGAJ for rheumatologists, UGAJ education in the rheumatology training curriculum and other structured education programmes in UGAJ was sent to three different groups: (i) all national rheumatology societies of EULAR; (ii) all national societies of the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB); and (iii) 22 senior rheumatologists involved in EULAR musculoskeletal US training from 14 European countries, who were also asked to circulate the questionnaire among relevant colleagues., Results: Thirty-three (75%) of 44 countries responded to the questionnaire (61.3% of national rheumatology societies, 25% of the national US societies and 100% of expert ultrasonographers). In the majority of countries (85%) <10% of rheumatologists routinely perform UGAJ in clinical practice, while the remaining countries (15%) reported a rate of 10-50%. The percentage of rheumatologists receiving training in UGAJ was <10% in the majority (72.7%) of countries., Conclusion: The study highlights the relatively low prevalence of UGAJ as compared with the high (>80%) rate of rheumatologists performing conventional joint injection in most of the surveyed countries. The reported variations in practice and the lack of available structured training programmes for trainees in most countries indicates the need for standardization in areas including training guidelines.

Objective: To document the current state of musculoskeletal US (MSUS) training and extent of implementation among rheumatologists in the member countries of EULAR., Methods: An English-language questionnaire, divided into five sections (demographics, clinical use of MSUS, overall MSUS training for rheumatologists, MSUS education in the rheumatology training curriculum and education in MSUS offered by the national rheumatology society) was sent by e-mail to three different groups: (i) all national rheumatology societies of EULAR; (ii) all national societies of the European Federation of Societies for Ultrasound in Medicine and Biology; and (iii) 19 senior rheumatologists involved in MSUS training from 14 European countries., Results: Thirty-one (70.5%) out of 44 countries responded to the questionnaire (59.1% of national rheumatology societies, 34.5% of the national US societies and 100% of expert ultrasonographers). Rheumatology was listed among medical specialties that mainly perform MSUS in 20 (64.5%) countries; however, in most [19 (63.3%)] countries<10% of rheumatologists routinely perform MSUS in clinical practice. Training varies widely from country to country, with low rates of competency assessment. MSUS education is part of the rheumatology training curriculum in over half the surveyed countries, being compulsory in 7 (22.6%) countries and optional in 11 (35.5%)., Conclusions: This study confirms the high uptake of MSUS across Europe. The reported variation in training and practice between countries suggests a need for standardization in areas including training guidelines.

Objectives: The authors examined the validity, interobserver reliability and interscanner variation in detecting bone erosions with ultrasonography using a custom-made phantom., Methods: 21 bovine bones were used. Artificial erosions were made into 15 bones and six bones were left as controls. In the processed bones the numbers of erosions, their depths and widths varied between 1-7, 1-4 and 1.5-5 mm, respectively. Each bone was coated with polyvinyl alcohol cryogel to mimic overlying soft tissue and to hide the erosions. Four musculoskeletal sonography experts scanned the 21 blind-coded phantoms using one of the three sets of ultrasound equipment. Finally, quality assurance measurements of the ultrasound equipment was carried out using two additional bone samples., Results: The sonographers detected the erosions successfully with ultrasound. The mean correlation coefficient for a correct result in terms of the number of erosions detected was 0.88 (range 0.75-0.975). The overall Cohen's kappa coefficient for interobserver agreement was 0.683 in terms of discrimination between healthy bones and bones with erosions. The different sets of equipment showed that their overall performance was equal., Conclusions: The sonographers had good correlations with the number of erosions and they were successful in separating healthy bones from bones with erosions. It seems that neither depth nor width is crucial but that in experimental conditions a 1.5 mm erosion width was the limit for the resolution with current ultrasound equipment. Ultrasound is a valid and reliable method of detecting cortical bone erosions in vitro, when the round erosion is at least 1 mm deep and 1.5 mm wide.

The objective of this study was to establish whether healthy persons have effusions detectable by ultrasonography (US) in metatarsophalangeal (MTP) and talocrural (TC) joints. Fifty consecutive healthy persons without symptoms in ankles and feet were studied. Thirty-eight of them were women, and their mean age was 47.4 (range 23-62) years. Eighteen of the 500 MTP joints studied in nine persons and four of the 100 TC joints in three persons showed effusions upon investigation. One person had effusion in five MTP joints, one in four, two in two, and the remaining five in one MTP joint. None of the studied joints yielded pathological findings in Doppler US examination. These results indicate that the detection of effusion by grayscale US in the absence of Doppler US in MTP and TC joints can be found in healthy persons.

Objective: To develop education guidelines for the conduct of future European League Against Rheumatism (EULAR) musculoskeletal ultrasound (MSUS) courses., Methods: We undertook a consensus-based, iterative process using two consecutive questionnaires sent to 29 senior ultrasonographer rheumatologists who comprised the faculty of the 14th EULAR ultrasound course (June 2007). The first questionnaire encompassed the following issues: type of MSUS educational model; course timing; course curriculum; course duration; number of participants per teacher in practical sessions; time spent on hands-on sessions; and the requirements and/or restrictions for attendance at the courses. The second questionnaire consisted of questions related to areas where consensus had not been achieved in the first questionnaire, and to the topics and pathologies to be assigned to different educational levels., Results: The response rate was 82.7% from the first questionnaire and 87.5% from the second questionnaire. The respondents were from 11 European countries. The group consensus on guidelines and curriculum was for a three-level education model (basic, intermediate and advanced) with timing and location related to the annual EULAR Congresses. The topics and pathologies to be included in each course were agreed. The course duration will be 20 h. There will be a maximum of six participants per teacher and 50-60% of total time will be spent on practical sessions. There was also agreement on prerequisite experience before attending the intermediate and advanced courses., Conclusion: We have developed European agreed guidelines for the content and conduct of EULAR ultrasound courses, which may also be recommended to national and local MSUS training programmes.

Ultrasound (US) is a relatively new imaging modality in rheumatology that offers great potential as a diagnostic and management tool. In 2004, an OMERACT Ultrasound Special Interest Group was formed to address the metric qualities of US as a potential outcome measure. A preliminary systematic review highlighted the deficiencies in the literature, particularly with regard to the reliability of interpreting and acquiring images; as a consequence, a number of exercises were proposed to address these issues. This report describes a series of iterative studies that have resulted in improved intra- and inter-reader reliability for detecting and scoring synovitis from both static and real-time images of the hand joints of patients with rheumatoid arthritis. The reliability of acquiring images was also enhanced using standardized positions. Future studies will assess the value of US in clinical trials.

Objectives: To examine the validity of power Doppler ultrasound imaging to identify synovitis, using histopathology as gold standard, and to assess the performance of ultrasound equipments., Methods: 44 synovial sites in small and large joints, bursae and tendon sheaths were depicted with ultrasound. A synovial biopsy was performed on the site depicted and a synovial sample was taken for histopathological evaluation. The performance of three ultrasound devices was tested using flow phantoms., Results: A positive Doppler signal was detected in 29 of 35 (83%) of the patients with active histological inflammation. In eight additional samples, histological examination showed other pathological synovial findings and a Doppler signal was detected in five of them. No significant correlation was found between the amount of Doppler signal and histological synovitis score (r = 0.239, p = NS). The amount of subsynovial infiltration of polymorphonuclear leucocytes and surface fibrin correlated significantly with the amount of power Doppler signal: r = 0.397 (p<0.01) and 0.328 (p<0.05), respectively. The ultrasound devices differed in showing the smallest detectable flow., Conclusions: A negative Doppler signal does not exclude the possibility of synovitis. A positive Doppler signal in the synovium is an indicator of an active synovial inflammation in patients. A Doppler signal does not correlate with the extent of the inflammation and it can also be seen in other synovial reactions. It is important that the quality measurements of ultrasound devices are reported, because the results should be evaluated against the quality of the device used.

Objective: To assess the intra-reader and inter-reader reliabilities of interpreting ultrasonography by several experts using video clips., Method: 99 video clips of healthy and rheumatic joints were recorded and delivered to 17 physician sonographers in two rounds. The intra-reader and inter-reader reliabilities of interpreting the ultrasound results were calculated using a dichotomous system (normal/abnormal) and a graded semiquantitative scoring system., Results: The video reading method worked well. 70% of the readers could classify at least 70% of the cases correctly as normal or abnormal. The distribution of readers answering correctly was wide. The most difficult joints to assess were the elbow, wrist, metacarpophalangeal (MCP) and knee joints. The intra-reader and inter-reader agreements on interpreting dynamic ultrasound images as normal or abnormal, as well as detecting and scoring a Doppler signal were moderate to good (kappa = 0.52-0.82)., Conclusions: Dynamic image assessment (video clips) can be used as an alternative method in ultrasonography reliability studies. The intra-reader and inter-reader reliabilities of ultrasonography in dynamic image reading are acceptable, but more definitions and training are needed to improve sonographic reproducibility.

Objective: To examine a contrast medium method using a glucocorticoid-air-saline mixture and ultrasound imaging (GAS-graphy) for the verification of palpation-guided injections in different joints and to assess the inter-reader reliability of the method., Methods: A palpation-guided injection of an air-steroid-saline mixture was given into a joint or tendon sheath of 133 consecutive patients. The dynamic ultrasound monitor images of the joints and tendons involved were videotaped before and after the injection. A rheumatologist and two radiologists analyzed separately the video clips of each patient, under blinded conditions. The readers evaluated the accuracy of the injections and the difficulty of the reading process. The inter-reader agreement was assessed by calculating the percentual values and overall kappa coefficient between the readers., Results: The overall accuracy of the successful injections was 76%, 80% and 82 % evaluated by the three readers. In six out of the ten injection sites the accuracy was higher than 80%. The clarity of the method evaluated by the readers was 8, 8 and 8.5 on a scale from 0 to 10. The inter-reader agreement assessed by percentual values was 84.2%, 85.0% and 88.7%. The kappa coefficient between all readers was 0.595 showing moderate agreement., Conclusion: The GAS-graphy method for the verification of palpation-guided injections is a simple procedure performable to any joint site and the result can be seen immediately on the monitor after the injection. The reliability of the method is good and it can be used in developing injection techniques as well as in medical or nurse education. The method can be used as an alternative for the radiographic contrast medium method in verifying successful palpation-guided intra-articular injections.

Objective: To assess the interobserver reliability of the main periarticular and intra-articular ultrasonographic pathologies and to establish the principal disagreements on scanning technique and diagnostic criteria between a group of experts in musculoskeletal ultrasonography., Methods: The shoulder, wrist/hand, ankle/foot, or knee of 24 patients with rheumatic diseases were evaluated by 23 musculoskeletal ultrasound experts from different European countries randomly assigned to six groups. The participants did not reach consensus on scanning method or diagnostic criteria before the investigation. They were unaware of the patients' clinical and imaging data. The experts from each group undertook a blinded ultrasound examination of the four anatomical regions. The ultrasound investigation included the presence/absence of joint effusion/synovitis, bony cortex abnormalities, tenosynovitis, tendon lesions, bursitis, and power Doppler signal. Afterwards they compared the ultrasound findings and re-examined the patients together while discussing their results., Results: Overall agreements were 91% for joint effusion/synovitis and tendon lesions, 87% for cortical abnormalities, 84% for tenosynovitis, 83.5% for bursitis, and 83% for power Doppler signal; kappa values were good for the wrist/hand and knee (0.61 and 0.60) and fair for the shoulder and ankle/foot (0.50 and 0.54). The principal differences in scanning method and diagnostic criteria between experts were related to dynamic examination, definition of tendon lesions, and pathological v physiological fluid within joints, tendon sheaths, and bursae., Conclusions: Musculoskeletal ultrasound has a moderate to good interobserver reliability. Further consensus on standardisation of scanning technique and diagnostic criteria is necessary to improve musculoskeletal ultrasonography reproducibility.

Objective: To evaluate the interobserver reliability among 14 experts in musculoskeletal ultrasonography (US) and to determine the overall agreement about the US results compared with magnetic resonance imaging (MRI), which served as the imaging "gold standard"., Methods: The clinically dominant joint regions (shoulder, knee, ankle/toe, wrist/finger) of four patients with inflammatory rheumatic diseases were ultrasonographically examined by 14 experts. US results were compared with MRI. Overall agreements, sensitivities, specificities, and interobserver reliabilities were assessed., Results: Taking an agreement in US examination of 10 out of 14 experts into account, the overall kappa for all examined joints was 0.76. Calculations for each joint region showed high kappa values for the knee (1), moderate values for the shoulder (0.76) and hand/finger (0.59), and low agreement for ankle/toe joints (0.28). kappa Values for bone lesions, bursitis, and tendon tears were high (kappa = 1). Relatively good agreement for most US findings, compared with MRI, was found for the shoulder (overall agreement 81%, sensitivity 76%, specificity 89%) and knee joint (overall agreement 88%, sensitivity 91%, specificity 88%). Sensitivities were lower for wrist/finger (overall agreement 73%, sensitivity 66%, specificity 88%) and ankle/toe joints (overall agreement 82%, sensitivity 61%, specificity 92%)., Conclusion: Interobserver reliabilities, sensitivities, and specificities in comparison with MRI were moderate to good. Further standardisation of US scanning techniques and definitions of different pathological US lesions are necessary to increase the interobserver agreement in musculoskeletal US.

The aim of this study was to compare the relationship between clinically detected swelling and effusion diagnosed by ultrasonography (US) in elbow joints in patients with rheumatoid arthritis (RA). Fifty consecutive patients with RA entered the study and 20 healthy persons formed a control group. Altogether 100 elbow joints of the RA patients and 40 of the controls were studied. All the clinical assessments were performed by one doctor and the US investigations by the other and they were blinded to each others results. In 77 elbow joints of the RA patients the clinical assessment and the US gave similar results, whereas they differed in the remaining 23 joints. The kappa coefficient between these investigations was 0.371. In the control group no elbow joint showed either swelling in the clinical assessment or effusion in the US investigation. The results of this study indicate that clinical assessment of swelling and evaluation of effusion by US in elbow joints in patients with RA show only fair agreement. Thus, US may improve the accuracy of diagnosis of synovitis in many cases in these patients.

Objective: To describe a new method for taking a synovial biopsy specimen under ultrasound guidance using portal and forceps., Methods: Percutaneous ultrasound guided biopsy was performed for 37 patients with mono- or polyarthritis as outpatients. A portal to a planned area was built using a needle, guiding wire, and dilators, through which forceps could be inserted and samples taken. Biopsy samples were taken from small and large joints, bursae, and tendon sheaths., Results: Representative synovial tissue in adequate amounts for histopathological evaluation was obtained in 33/37 cases--a success rate of 89%. The biopsy procedures were well tolerated, but one complication of skin infection was encountered., Conclusion: The new method of synovium biopsy under ultrasound guidance using sheath introducer set and flexible forceps can be performed on most joints and even bursae and tendon sheaths. The method gives sufficient samples for clinical work in most cases, but further work is needed before accepting this promising technique for scientific purposes.

Objectives: To investigate experimentally the echogenicity of air, a steroid suspension and physiological saline mixed with water in order to find the best contrast medium for injections. To show the practical applications of an airsteroid-saline mixture as a contrast medium in rheumatology., Methods: In vitro. First, quality assurance measurements were conducted twice on the ultrasound (US) equipment. Subsequently air, a steroid suspension, or physiological saline mixed with water, first alone and then in different combinations, were examined with US using quantitative image analysis. Clinical. The effectiveness of an air-steroid-saline mixture as contrast medium in ultrasonography was tested in joint, bursa and tendon sheath injections., Results: In vitro. Based on the quality assurance measurements the physical performance of the US equipment was excellent. Verified visually and quantitatively the mixture of air, steroid and saline produced the best contrast on US. The importance of air bubbles producing contrast was obvious. Clinical application. Firstly, visualisation of the contrast medium with US made it possible to follow in real-time the passage of a drug to the target area. Secondly, the use of the contrast method verified the presence of steroid in the synovial target intended after a blind injection. Thirdly, anatomical and pathologic anatomical connections could be visualized using this contrast medium in the wrist, shoulder, knee, ankle and foot joint, Conclusions: Verification of US system performance by quality assurance measurement is essential for US imaging. The air-steroid-saline contrast medium method of ultrasound scanning is a somewhat invasive, but inexpensive and rapid method. It can verify the existence or non-existence of an air-steroid-saline contrast medium in the desired place and in adjacent structures, thus showing possible pathologic anatomic connections. The method has a diagnostic and therapeutic value, and expands the interventional spectrum of sonographic imaging.

Objective: To assess the relationship between clinically detected swelling and effusion diagnosed by ultrasonography (US) in metatarsophalangeal (MTP) and talocrural (TC) joints in patients with rheumatoid arthritis (RA)., Methods: Thirty consecutive patients with RA were studied. Altogether 288 MTP joints and 60 TC joints were evaluated. The clinical investigations were carried out by one doctor and the US investigations by another and they were blinded to each others' results., Results: The clinical examination and US gave similar results in 194 MTP joints, whereas they differed in the remaining 94 MTP joints, and correspondingly the results were similar in 34 TC joints and differed in 26 TC joints. The kappa coefficient between these investigations was 0.165 in MTP joints and 0.043 in TC joints, showing very poor agreement., Conclusion: These preliminary results showed poor agreement between the clinical assessment of swelling and effusion detected by US in MTP and TC joints. Thus US may considerably improve the diagnosis of synovitis in patients with RA.

Fifty consecutive patients with RA and clinical wrist synovitis were randomly allocated to either receive an injection of glucocorticoid into the radiocarpal joint or have the same amount of drug divided into the radiocarpal and midcarpal joints. Inferior radioulnar joint synovitis was treated with extra steroid injection only in the latter group. Patient's and doctor's assessments as well as ultrasonography improved significantly at month 3 in both groups. A statistical difference between the groups was found in the midcarpal joint measurement favouring the extra midcarpal injection. Ten wrists (20%) were normal when assessed with ultrasound at month 3 while 34 wrists (68%) were normal on clinical assessment.

Ultrasonography has gained popularity among rheumatologists especially in Europe as a bedside imaging method for diagnosing soft tissue lesions such as synovitis in joints, bursae and tendons. In addition to diagnosing the lesion ultrasound can be used to monitor needle position during the injection procedure. The aim of this paper is to describe injection techniques guided by ultrasound into the joints, bursae or tendon sheaths. We point out that the value of ultrasound in rheumatology is not only diagnostic but also therapeutic.

Objective: To study the plantar forefoot of patients with early rheumatoid arthritis (RA) by ultrasound to detect bursitis and to correlate sonographic findings with symptoms and clinical observations., Methods: Clinical examination, dorsoplantar radiographs, and transverse sonographic scans of the plantar region of the forefoot were performed on 30 healthy persons as well as 25 patients with early RA and forefoot symptoms., Results: In 8 patients the examiner could clinically suspect plantar bursitis. Ultrasound revealed 22 incidents of plantar bursitis in 14 of the 25 patients. Except for bursitis in the forefoot no inflammatory findings were detected by ultrasound in 6 patients., Conclusion: Not only metatarsophalangeal arthritis or flexor tenosynovitis but also plantar bursitis can promote symptoms of the forefoot. Ultrasound is a more objective procedure than clinical examination in diagnosing plantar bursitis. This finding has diagnostic and therapeutic implications.

Three cases of transient osteoporosis of the hip and their ultrasonographic findings are presented. Transient osteoporosis of the hip is an uncommon condition with pain in the hip area and limping. The diagnosis is supported by local radiological osteoporosis and other imaging methods. Exclusion of more common entities is required. Effusion of the hip joint detected by ultrasonography is also related to this condition, which must be taken into account in patients with hip pain.

Two cases of unilateral abnormal ultrasonographic findings in the hip joints are introduced. The correct diagnoses were detected by radiography after the failure of intra-articular glucocorticoid injections given as first aid. Ultrasonography (US) has poor specificity, since all phenomena causing effusion into the joint cavity may be detected as abnormal by US, and may include stress fractures and malignant myeloma, as we show here. In the case of an abnormal ultrasonographic finding in a joint, the recent radiological status should also be considered.

An ultrasonographic method for detecting intraarticular effusion in subtalar and midtarsal joints was developed. An unechogenic zone in these joints is a sign of intraarticular effusion or synovitis. It is also possible to inject glucocorticoid into these small joints with the guidance of ultrasonography.

Desensitization to sulphasalazine was successful in 16 of 21 (76%) arthritic patients who previously had skin rash from sulphasalazine (success rate: 8 of 13, or 62%) or sulphonamide (success rate: 8 out of 8 patients). Desensitization to sulphasalazine is a simple outpatient procedure which allows many subjects who develop a skin rash to sulphonamide or sulphasalazine to start or continue sulphasalazine treatment.

The central joints of 19 patients identified as suffering from polymyalgia rheumatica were examined using ultrasonography (US). At US 13 patients (68%) were found to have an effusion in the hip and/or glenohumeral joints. Synovial fluid analyses were conducted on the central joints of four patients. These findings suggest that at least one patient group with the syndrome of PMR could better be designated as having axial arthritis and this synovitis might play an important role in the understanding of their symptoms.

Sixty radiocarpal and midcarpal joints in 30 healthy adults and 20 swollen wrists in 20 patients with chronic arthritis were examined by dorsal longitudinal ultrasonography (US). In five other patients intraarticular application of fluid into the radiocarpal joint could be seen as a change in the US scan. In 49 out of the 60 healthy wrists the unechogenic zone dorsally above the scaphoid bone was less than two millimetres, and the measurement did not change in dorsal or volar flexion. The side difference was less than one millimetre. In the healthy wrists the midcarpal area above bones was echogenic in US. In 15 radiocarpal and in 10 midcarpal joints out of the 20 swollen wrists, effusion could be depicted with US as an unechogenic zone. It was two millimetres or more in radiocarpal joint and it got bigger in dorsal and smaller in volar flexion.

The usefulness of ultrasonography in detecting intra-articular effusion of the hip joint is discussed in the light of three cases. In all these patients, effusion was demonstrated by ultrasonography and confirmed by aspiration of inflammatory synovial fluid from the joint, though the joint was clinically symptomless. It is recommended that all rheumatologists use ultrasonography.

The unechogenic space between the bone and the joint capsule in 280 metatarsophalangeal (MTP) joints and in 56 talocrural (TC) joints of 28 healthy adults was measured by ultrasonography. These normal values were compared with those of 40 arthritic MTP and of 15 arthritic TC joints. The unecogenic space in the MTP joints was more than 3 mm in 12 out of 280 healthy joints during dorsiflexion. In arthritic joints the space was more than 3 mm in 31 out of 40 joints, and the mean value was significantly higher than in the healthy joints. An unechogenic space could be demonstrated in all the arthritic but none of the healthy TC joints. An unechogenic space of more than 3 mm in a dorsiflexed MTP joint and demonstration of an unechogenic space in a TC joint are signs of intra-articular effusion or synovitis.

The ultrasonographic distance between the collum of the femur and the capsule of the hip joint was measured in 88 hips of 75 patients with chronic inflammatory joint disease and with hip joint symptoms or signs. In addition, 10 other hips were measured before soft tissue operation of the hip joint. The ultrasonographic distance was 7 mm or more in 29 out of 33 hips with synovial fluid in joint puncture and in seven out of nine hips with intra-articular effusion or synovitis in open surgery. Intra-articular injection of corticosteroid resulted in a significant decrease in the enlarged ultrasonographic distance, in joints both with and without synovial fluid. Joints not treated with steroid did not show any change. It is concluded that both joint effusion and synovitis without effusion can increase the anechogenic distance between the bone and the joint capsule.

The nonechogenic space between the bone and the joint capsule was measured in ultrasonographic scans at six different sites in 60 elbow joints of 30 healthy adults as well as in 35 joints with clinical arthritis. The space could be demonstrated in all healthy joints on the volar side at the levels of the trochlea and the capitulum of the humerus. The space was more than 2 mm in three out of the 60 healthy joints at these levels, and the space did not increase in 30 degrees flexion of the joint. The means of the measurements were significantly higher at all six sites in the arthritic joints than in the healthy joints and on the volar site the space increased in 30 degrees flexion of the arthritic joint. The space was more than 2 mm in all arthritic joints at the levels of either the trochlea or the capitulum of the humerus. An ultrasonographic distance of more than 2 mm on the volar side of the elbow joint between the joint capsule and the bone is with high probability a sign of intraarticular effusion or synovitis. The effusion in the olecranon fossa can also be demonstrated in all cases.

The ultrasonographic distance between the hip joint capsule and femur was measured in 75 healthy adults. The mean distance was 5.1 (SD 0.7) mm. The shortest distance was 3.0 mm, the longest 7.0 mm. The difference between the right and left hip was 0.3 (SD 0.3, range 0-1.2) mm. No correlation was found between the ultrasonographic distance and the subjects' height, body weight, age or sex. The reproducibility of the measurement was good, and the interobserver correlation was 0.94. It is concluded that an ultrasonographic distance between the hip joint capsule and the femur of 7 mm or more, and a difference between the hips of 1 mm or more suggest an intracapsular effusion in the joint in adults.

A new ultrasonographic method for detection of intraarticular effusion in the glenohumeral joint was developed. The distance between the humerus and the joint capsule is measured at the axilla with the humerus in 90 degrees abduction. Effusion was detected by ultrasonography in 10 of 11 joints in which effusion was confirmed by intraarticular puncture. Intraarticular injection of physiological NaC1 solution could be seen as a change in the scan. The mean ultrasonographic distance between the head of humerus and the joint capsule was 2.4 mm (SD 0.5 mm) in 80 shoulder joints of 40 healthy adults. Thus, intrasynovial effusion can be suspected if the distance is 3.5 mm (mean + 2 SD) or more, or the difference between both sides is 1 mm or more.

One hundred non-operated hip joints in 50 adult patients with active rheumatoid polyarthritis were examined by ultrasonography as well as by clinical methods and X-ray. In 15 hip joints in 11 patients, ultrasonography indicated intra-articular effusion (a distance between the joint capsule and bone of more than 7 mm in 14 and a difference between the two sides of more than 1.5 mm for one hip). There were no subjective symptoms associated with five of these hip joints, the X-ray findings were normal for 11 hips, and careful clinical examination showed normal findings for one hip joint. The routine clinical examination used in the hospital had revealed pathological findings in only two of these hip joints. It is concluded that ultrasonography may reveal intra-articular effusion or synovitis in clinically and radiologically apparently normal hip joints of patients with active rheumatoid arthritis. The increase in pain and restricted motion was statistically significant in the hips for which ultrasonography indicated intra-articular effusion. Hips that appear pathological in ultrasonography are thus synovitis, and do not fall within the range of normal variation for healthy hip joints.